Welcome to our Infection Catalyst Event

Follow us on Twitter @NWCAHSN @LiverpoolUni

Introductions and welcome

Prof John Goodacre, NWC AHSN Prof Nigel Cunliffe, University of Liverpool

Follow us on Twitter @NWCAHSN @LiverpoolUni

Networking

Healthcare / NHS

Industry

Academia

Thank you to all our exhibitors:

5D Health Protection Group Ltd

Mr Archie Veale Patient representative

Staphylococcus Aureus Panton-Valentine Leukocidin+

Septicaemia

Continuous Veno Venous

Haemofiltration

(CVVH)

Tracheostomy

Extracorporeal Membrane

Oxygenation (ECMO)

Alter-G Anti-Gravity Treadmill

Wheelchair Basketball

What could have been done? • “…although urine and blood

samples were taken I was sent home with some strong painkillers”

• “Two major tell tail signs of the early stages of an infection”

• “An opportunity was definitely missed”

• Glucose in my urine • High blood sugar

levels • Bloody sputum

Enter subtitle here (24pt, Arial Regular)

Enter date: 25.06.13

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

A NATIONAL APPROACH FOR SEPSIS

IN IRELAND

- LESSONS FROM THE FIRST YEAR

Dr. Fidelma Fitzpatrick

Chair, National Sepsis Steering Group

Senior Lecturer, Royal College of Surgeons in Ireland &

Consultant Microbiologist, Beaumont Hospital, Dublin, Ireland

@ffitzP

BACKGROUND – HEALTHCARE IN THE

REPUBLIC OF IRELAND

Source: hse.ie

• External regulator

(HIQA)

• 5 HSE divisions

1. Acute hospitals

2. Social Care

3. Mental Health

4. Primary Care

5. Health & Wellbeing

SEPSIS IN IRELAND

OUTLINE

1. The National Sepsis Steering Group

2. National Guidelines

3. The first year

a. Speaking a common language

b. Establishing the burden

c. The importance of the first hour

d. Making it easier to diagnose sepsis

e. Making tools readily available

4. Where do we go next?

1. THE NATIONAL SEPSIS STEERING GROUP

• Established July 2013

• Multidisciplinary (33 people!)

– Patient Representation

– Hospital, pre-hospital and primary care

– National Clinical Programmes

– Junior doctor

– Hospital manager

– External expert: Prof Kevin Rooney

• Sepsis lead appointed mid 2014: Dr. Vida Hamilton

2. NATIONAL GUIDELINES

3. THE FIRST YEAR

- GUIDELINES ARE ONLY THE

STARTING POINT

IMPLEMENTING THE 2005 IRISH NATIONAL MRSA GUIDELINES

• Education

– (hand hygiene , antibiotic stewardship)

• Governance

• Infrastructure

• Bed occupancy

• Laboratory resources

• Infection control specialist staffing

Challenges of Implementing National Guidelines for the Control and Prevention of Methicillin‐Resistant Staphylococcus aureus Colonization or Infection

in Acute Care Hospitals in the Republic of Ireland ICHE 30, No. 3 (March 2009), pp. 277-281

IMPLEMENTING IRISH STROKE GUIDELINES

‘The introduction of stroke clinical guidelines at a national

level is not sufficient to improve health care quality’

Donnellan C, et al. Implementing clinical guidelines in stroke: A qualitative study of perceived facilitators and

barriers. Health Policy (2013), http://dx.doi.org/10.1016/j.healthpol.2013.04.002

THE CHALLENGES

GUIDELINE

Lots of attention

DISSEMINATION

Usually published – sometimes education

IMPLEMENTATION

LESS ATTENTION++

Qual Health Care 1993; 2(4);243-8 Qual Health Care 1994; 3(1);45-52 The Psychiatrist (2004) 28: 8-11

Guideline implementation

Behaviour

Knowledge

Attitudes

JAMA. 1999;282(15):1458-1465. doi:10.1001/jama.282.15.1458

“If I read and memorized two medical journal articles

every night,

by the end of a year

I’d be 400 years behind.”

http://e-patients.net/archives/2013/08/400-years-behind-updated-bigtime.html

FROM THE START

• Dissemination

• Care pathway for every patient diagnosed with sepsis in

Ireland

• Recognition, Resuscitation, Referral

• Tools, Education, audit

• First things first…..

A. SPEAKING A COMMON

LANGUAGE

He

looks

‘septic’

He has

septicaemia He is

‘septic’

He has no

obvious

source of

sepsis’

He must have

sepsis as he

has gone off

Bone et al. Chest, 1992, 101:1644

COMMON DEFINITIONS

SIRS

•Infectious & non infectious causes

•Clinical response arising from a non specific insult

Sepsis

•SIRS plus

•Presumed or confirmed infection

Severe Sepsis

•Sepsis plus

•Sepsis-induced organ dysfunction or tissue hypoperfusion

Septic Shock

•Sepsis-induced hypo-perfusion or hypotension persisting despite 30 mls/kg fluid resuscitation

INFECTION

• A pathological process caused by invasion of normally

sterile tissue or fluid or body cavity by pathogenic or

potentially pathogenic micro-organisms.

• Causes by bacteria, viruses, fungi, parasites

• Infection can be present without being microbiologically

confirmed.

Source: National Sepsis Guidelines -

http://www.hse.ie/eng/about/Who/clinical/natclinprog/sepsis/summary%20sepsis%20management.pdf

SIRS - SYSTEMIC INFLAMMATORY

RESPONSE SYNDROME

• Clinical response to nonspecific insult

– Characterised by abnormal vital signs

• SIRS can be caused by infectious + non infectious causes

• Infection

• Ischaemia

• Haemorrhage,

• Inflammation (e.g. pancreatitis)

• Trauma

• Burns

SIRS (MODIFIED)

• Temperature > 38°C or < 36°C

• Heart rate > 90 beats/min

• Respiratory rate > 20 breaths/min

• WCC > 12 or < 4

• Blood glucose > 7.7 mmol/l in non-diabetic

• Altered mental status

SEPSIS

• Sepsis is the systemic response to infection

• The clinical syndrome defined by both

– Infection + the systemic inflammatory response

syndrome (SIRS).

Sepsis = SIRS + infection

Source: National Sepsis Guidelines -

http://www.hse.ie/eng/about/Who/clinical/natclinprog/sepsis/summary%20sepsis%20management.pdf

COMMON INFECTIVE SOURCES OF SEPSIS

SEVERE SEPSIS

• Severe sepsis refers to sepsis complicated by organ

dysfunction

SEPTIC SHOCK

• Severe sepsis

PLUS

• persistent hypotension and perfusion abnormalities

DESPITE

• adequate fluid resuscitation

SPEAKING A COMMON

LANGUAGE

He has

SEPSIS

B. ESTABLISHING THE BURDEN

“IN GOD WE TRUST-

ALL OTHERS BRING DATA.”

W. E. DEMING

ESTABLISHING THE BURDEN – SEPSIS IS

COMMON AND KILLS

International estimates

• Sepsis: 300 per 100,000 per annum

• Acute myocardial infarction: 208 per 100,000 per annum

• Mortality: 20 - 55%

Breast cancer

THE BURDEN IN IRELAND – HIPE DATA

• 60% all in-hospital deaths has a code of ‘sepsis’ or

‘infection’ diagnosis

– But cant infer causality

• 2013: Sepsis:

– Cases = 8,770

– Bed days = 220,288

2013 2012 2011

In-hospital mortality* 28.8%

31.3% 32.4%

Source: Dr. Vida Hamilton, National Sepsis Lead

* Critical care area

THE REALITY OF SEPSIS

2013 Without With

ALOS Sepsis 5.59 26

ALOS Infection 5.59 10

ALOS Maternity 2.61 5.47

ALOS Paediatrics

3.08 22.19

Source: Dr. Vida Hamilton, National Sepsis Lead

AGE STANDARDISED HOSPITAL DISCHARGE

RATE FOR MEDICAL SEPTIC SHOCK

2005 - 2012

SEPSIS 2013

National Average

Sepsis cases

- as % of all cases

- as % of all bed days

1.44

6.8

Sepsis + Infection

- as % of all cases

- as % of all bed days

20.22

42.3

Source: Dr. Vida Hamilton, National Sepsis Lead

COSTS

Sepsis consumes 30% of the UK critical care budget

• £20,000 per patient

• £2.5 billion annually

• Chronic health burden for survivors

Iwashyna et al: Long-term cognitive impairment & functional disability among survivors of severe sepsis.

JAMA, 2010.

16.8

3.8

6.2

7.1

0 5 10 15 20

Moderate-severe

Mild

Before sepsis After sepsis

COSTS - COGNITIVE IMPAIRMENT

C. ESTABLISHING SEPSIS AS A

TIME DEPENDENT EMERGENCY

• 90% of cases with poor outcome in

the Australian sepsis database,

inadequate recognition was found to

be the most common feature

0%

100%

Time (Hours)

1 3 6

Adapted from: Kumar A, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the

critical determinant of survival in human septic shock. Crit Care Med 2006; 34(6):1589–96

EARLY APPROPRIATE ANTIBIOTICS SAVES

LIVES

D. MAKING IT EASIER TO

DIAGNOSE SEPSIS

SEPSIS

IT CAN BE DIFFICULT ESPECIALLY EARLY ON!

“…as the physicians say it happens in hectic fever,

that in the beginning of the malady it is easy to

cure but difficult to detect, but in the course of

time, not having been either detected or treated in

the beginning, it becomes easy to detect but

difficult to cure”.

Niccolo Machiavelli, The Prince, 1513

• Not all patients have classic SIRS

• Some groups at special risk

– e.g. neutropenia, haemodialysis, diabetes mellitus, alcoholism, lung

disease, patients with invasive devices

Laupland et al Crit Care Med 2004

• Elderly patients (age > 65 years)

• Decreased inflammatory response

• Often not febrile

• More likely to be delirious

• Falls may be only evidence of sepsis-induced delirium

• More likely to develop septic shock and multiple organ dysfunction

syndrome

DIAGNOSING SEPSIS CAN BE DIFFICULT

IMPROVING SURVIVAL

• Early Recognition

• Appropriate intervention – Resuscitation

• Appropriate Referral - critical care expertise

SEPSIS SCREENING

• Early Recognition

• 2% of all ED referrals are due to sepsis

• NSW audit of NEWS: sepsis is the cause of 30% of

triggered reviews

• UK: NEWS > 5; 52% sepsis

ED VS IN-PATIENT

ED

• Community acquired

• Less co-morbidities

• Generalised training

• Mortality 20%

Ward

• Hospital acquired

• Co-morbidities

• Second – Hit

• Specialist training

• Mortality ??? Higher

ONCE SEPSIS RECOGNISED –

THE IMPORTANCE OF 6 IN 60

SEPSIS 6 IN 1ST HOUR

3 to give 3 to take

1. O2 (94-98% or 88-92%) 1. Blood cultures & other

appropriate cultures

2. IV antibiotics 2. FBC, Lactate

3. IV fluids 3. Assess urinary output

MANAGEMENT OF SEPSIS IN ADULT IN-

PATIENT

ANTIBIOTICS - START SMART

• 9-fold increase in mortality with inappropriate antibiotics

• Independent risk factors

– COPD

– Immunocompromised

– Chronic dialysis

COMPLIANCE WITH SEPSIS 6

• Reduces the relative risk of death by 46.6%

• 1 additional life saved for every 5 care episodes

• Mortality reduced from 44% to 20%

• Daniels et al, Emergency medicine journal 2011

COMPLIANCE WITH SEPSIS 6

IS THAT IT?

• Sepsis 6 is the minimum intervention

• Sepsis is a continuum

• Source control

• Seasonal and other outbreaks, recent travel, patient at

risk of antibiotic resistant organisms

E. MAKING TOOLS READILY

AVAILABLE

www.hse.ie/sepsis

BARRIERS TO IMPLEMENTATION

• Lack of awareness, Lack of agreement

• Lack of self-efficacy

– Perception – Reality gap, Education, Audit

• Lack of outcome expectancy

– Audit

• Inertia of previous practice

– Lactate, Audit, Discussion forums, Bottom-up/ Top-down

EXTERNAL BARRIERS

• Guideline related

– Lack of maternity guidelines

– Poor specificity of SIRS criteria

• Patient related

– Late presentation, co-morbidities

• Environment related

– Lack of resources

OVERCOMING BARRIERS

• Education

• Audit

– HIPE, KPI, ward-based audit

• Resourcing

SO WHERE TO NEXT THIS YEAR?

• Educational tools

– App / E learning / Educational video

• Hospital visits by sepsis lead

• Patient education and awareness

• Sepsis summit July 2015

• Better data

– New HIPE codes

• Monitor progress

– Compliance i.e. form present in chart aim is to attain 95%

compliance by 2018

– Mortality from sepsis

– Mortality from severe sepsis

– Incidence of sepsis per 100,000 population.

IN SUMMARY

• Sepsis is a Medical Emergency

• Awareness, Screening, Recognition

and Prompt Treatment is the Key to

Reliable Rescue

ACKNOWLEDGEMENTS

• Dr. Vida Hamilton, National Sepsis Lead, Ireland

• Dr. Ron Daniels

• UK Sepsis Trust

• Prof. Kevin Rooney

HTTPS://WWW.YOUTUBE.COM/WATCH?V=ECD

PQ74DXFM

Improving the diagnosis of sepsis using

point -of-care tests

Enitan D Carrol

Chair in Paediatric Infection

Infection Catalyst Event 29 April 2015

Background

• Estimated 18 million cases worldwide annually. Developing world, > 6 million neonates and children die/yr

• In UK, 36 –64,000 deaths per year attributed to severe sepsis, cost to the NHS/year ~ £2.3 billion

• Mortality 28-50%

• Incidence rising: ageing population, antibiotic resistance, survival from cancer, new treatments

• Delays in diagnosis: symptoms and signs non-specific, deterioration rapid, inadequate diagnostic tools

• Sepsis is a medical emergency

Neutrophil Gelatinase Associated Lipocalin (NGAL)

Resistin

Procalcitonin

PROMPT SEPSIS: Partnership for Rapid On-Site

Microfluidic POC Test for Sepsis

July 2012- October 2014

Conjugate release pad

Nitrocellulose membrane

Absorbent pad

Conjugated particles (immobilised)

(T3) Control Line (C)

Multiplex Sandwich Assay Schematic

Target capture antibody (anti-PCT)

Control capture antibodies (Anti-mouse + goat IgG)

Anti-PCT + RES + NGAL gold nanoparticle conjugate

Sandwich LFD format

Biomarker in the sample: No biomarker in the sample:

Test Lines (T2) (T1)

Target capture antibody (anti-RES)

Target capture antibody (anti-NGAL)

Y

Sample well Viewing window

anti-RES pAb and anti-biotin pAb conjugated to 40nm gold detector

particles anti-RES pAb

Biotin-BSA

Y

T C

Y

anti-PCT pAb and anti-biotin pAb conjugated to 40nm gold detector

particles anti-PCT pAb

Biotin-BSA

Y

Y

anti-NGAL pAb and anti-biotin pAb

conjugated to 40nm gold detector particles anti-NGAL

pAbBiotin-

BSA

Y

A

B

C

D

E

Gold conjugate pad

NC membrane Wick pad

Y

Sample well Viewing window

anti-RES pAb and anti-biotin pAb conjugated to 40nm gold detector

particles anti-RES pAb

Biotin-BSA

Y

T C

Y

anti-PCT pAb and anti-biotin pAb conjugated to 40nm gold detector

particles anti-PCT pAb

Biotin-BSA

Y

Y

anti-NGAL pAb and anti-biotin pAb

conjugated to 40nm gold detector particles anti-NGAL

pAbBiotin-

BSA

Y

A

B

C

D

E

Gold conjugate pad

NC membrane Wick pad

The POC system developed incorporates 3 simplex lateral flow assays utilising gold nanoparticle technology to detect (a) NGAL, (b) PCT and (C) RES. (d) vertical plan view of assay strip and (e) vertical plan view of housed assay.

R² = 0.680

0

100

200

300

400

500

600

0 100 200 300 400 500 600

Exp

ecte

d N

GA

L C

on

cen

trat

ion

(ng/

ml)

Actual NGAL Concentration (ng/ml)

NGAL

R² = 0.800

0

100

200

300

400

500

600

700

800

0 100 200 300 400 500 600

Exp

ecte

d R

ES C

on

cen

trat

ion

(ng/

ml)

Actual RES Concentration (ng/ml)

RES

R² = 0.912

0

100

200

300

400

0 100 200 300 400 500 600

Exp

ecte

d P

CT

Co

nce

ntr

atio

n (n

g/m

l)

Actual PCT Concentration (ng/ml)

PCT

A B

C

R² = 0.680

0

100

200

300

400

500

600

0 100 200 300 400 500 600

Exp

ecte

d N

GA

L C

on

cen

trat

ion

(ng/

ml)

Actual NGAL Concentration (ng/ml)

NGAL

R² = 0.800

0

100

200

300

400

500

600

700

800

0 100 200 300 400 500 600

Exp

ecte

d R

ES C

on

cen

trat

ion

(ng/

ml)

Actual RES Concentration (ng/ml)

RES

R² = 0.912

0

100

200

300

400

0 100 200 300 400 500 600

Exp

ecte

d P

CT

Co

nce

ntr

atio

n (n

g/m

l)

Actual PCT Concentration (ng/ml)

PCT

A B

C

Actual vs. expected concentration of (a) NGAL, (b) PCT and (c) RES in spiked human plasma samples.

• Lack of correlation with measured biomarkers on clinical

samples

• Cross reactivity of antibodies, unable to multiplex

• Biomarkers did not offer sufficient discrimination of sepsis

• Search for alternative bio-recognition molecules

• Electrochemical POC test

• Peptide aptamers (Affimers) on gold electrode

Limitations of LFD approach to POC diagnostic

The picture above, adapted from - S Jenko et al.

(2003) J Mol Biol 326: 875-885 shows a co-crystal

between Stefin A and its natural partner, cathepsin H.

• Affimers are small, single domain proteins based on the

human protease inhibitor Stefin A.

• Stefin A, which uses three surfaces to interact with its

target, has been engineered to remove any reactivity of its

basic core with human targets and improve the stability of

the new protein which is called the Affimer “scaffold”.

• The scaffold displays two loops and the amino terminus, a

similar interaction surface to the variable region of an

antibody.

• The Affimer’s ability to recognise and bind a specific target

is endowed by the amino acid sequences of these binding

surfaces.

What is an Affimer?

Johnson A, Analytical Chemistry 2012

Affimers present surfaces of low initial steric bulk and charge

transfer resistance and are highly responsive to target binding

Antibody on a PEGylated gold electrode

Affimer on a PEGylated gold electrode

Antigen

C

D

Reporter

molecule

Point-of-care diagnostic for sepsis

Qualitative Reading

Quantitative Reading

108

Communication device

Telehealth facilities Clinical decision

Stuart Carter Professor of Veterinary Pathology

Making a vaccine:

working with industry

2005 - Venture capitalists: • Develop new vaccines? • Not a chance – no profit 2015 – Biotech companies: • Anti-microbial drug resistance • Post-genomic era • Very interested….

Science and Finance

Digital Dermatitis Research at

Liverpool Veterinary School

Digital Dermatitis:

a preventable infectious lameness

caused by novel bacterial infections

School of VETERINARY SCIENCE

Liverpool & Leahurst

The problem: Bovine Digital Dermatitis

An emerging disease of cattle, sheep and goats which causes severe lameness. Major cost to cattle industries.

Only Liverpool Vet School can routinely isolate and grow the causative bacteria

Can we make an effective vaccine to

prevent disease?

Genome sequences

Modelling of surface proteins

Select antigens

Design recombinant

vaccine

Bacterial cocktail

Vaccine trial

From our isolates?

From the genomes?

Currently funded by big pharma (Zoetis - ex-Pfizer) to make a vaccine for digital

dermatitis by reverse vaccinology approaches.

Looking for more partners…

University researchers working with Industry

Opportunities for both • Very good value for company as research infrastructure and expertise is

immediately available • Funding stream for academics • Scale up benefits eg testing and production • Access to pool of researchers and funders. • Access to UK Research Council support for joint projects

• Eg BBSRC gives 50% costs for LINK award and 90% for IPA Disadvantages • Can be quick or slow progress

• Success not guaranteed as research is involved • Academic requirements eg rapid publishing • IP ownership • Patent issues

Major opportunity overall for both parties

That’s all folks……

That’s quite

enough.

Get orf!

That’s all folks……

A blood test for improving diagnosis of central

nervous system infection? or

“Do you wear a pink shirt?” Dr Michael Griffiths

Senior Clinical Lecturer / Paediatric Neurologist Brain Infections Group

Institute of Infection Global Health University of Liverpool

29/4/15

Scan shows inflamed lining of brain

Improving diagnosis of central nervous system infection?

Rationale Currently limited predictive tests for central nervous system (CNS) infection Pathogen culture from CSF can be insensitive (if low bacterial load / selective growth conditions ) Indirect pathogen detection (i.e. PCR) Can give false negative - particularly if not sure what the pathogen looking for. Doesn’t discriminate between acute / past infection Other CSF parameters (glucose, protein) limited sensitivity / specificity Blood biomarkers for CNS infection offer: • Quick / easy to take blood • Encourage need to undertake Lumbar Puncture – help expediate this procedure • Improved patient management - earlier decision on antimicrobial / antiviral treatment

Team doing lumbar puncture in Indonesia to rule out infection

Principle Different CNS diseases generate different human host responses Differences in the human host response (cell state) correlate with differences in gene expression These differences can be identified by examining patterns of transcript abundance in patient’s leukocytes Aim Identify diagnostic markers that discriminate between shunt infection and malfunction.

“Do you wear a pink shirt?”

Whole-blood gene-expression can distinguish between different meningitis patients

Bacterial Meningitis

n=17

Meningism n=23

Viral Meningitis

n=21

Transcripts highly abundant in Bact. Men.

Transcripts highly abundant in Viral. Men.

Whole-blood gene expression patterns of patients from our Meningitis NW study (n=61) with proven Bacterial meningitis compared to patients with Meningism (CSF wcc <4cells/ul;) or patients with proven Viral meningitis.

Increased

Decreased

Griffiths McGill Gosia et al.

Bacterial Other

Test+ 17 9

Test- 0 35

Sens. 100% (17/17) Spec. 79.5% (35/44)

Bacterial Meningitis

n=17

Meningism n=23

Viral Meningitis

n=21

Array data Genes selected by PAM

Ratio > 1.18 predict BM

BM:VM ratio (based on 4 genes) correctly predicted sample class in 29/30 (97%) patients

Array data can be reduced to a subset of 4 genes that detect bacterial meningitis (n=30 [duplicate samples])

This point represents a ratio of >1.18. It gives 100% sensitivity and 95% specificity for identifying samples from patients in the BM group

Same subset of 4 genes detect bacterial meningitis (n=13) from meningism or viral meningitis (controls; n=88; independent samples)

This point represents a ratio of >1.18. It gives 84% sensitivity and 74% specificity for identifying samples from patients in the BM group

Ratio (based on 4 genes) correctly predicted sample class in 76/101 (75%) patients Markers tested in sample set with

real life prevalence of BM (approx 10%)

FTD ceo

Generated meta-data training set 180 samples - 71 bacterial meningitis - 109 other from 5 array experiments (2 in-house – 3 GEO) 80,000 potential markers

Tested the array data (n=180 samples) Using a variety of classification algorithms Selected marker sets with AUC >0.8 190 + markers

Generated meta-data training set 180 samples - 71 bacterial meningitis - 109 other from 5 array experiments (2 in-house – 3 GEO) 80,000 potential markers

Tested the array data (n=180 samples) Using a variety of classification algorithms Selected marker sets with AUC >0.8

Tested marker combinations in array data (n=180 samples) Selected marker comb. with sens. >80% spec. >80% Best – identified markers 100% sens 85% spec.

Tested markers in overlapping PCR samples (n=30) + compared to array data for these samples (n=30 ) Selected marker comb. Sens >80% Spec >80% (Sig & diff. between classes) 30+ markers [Some not performing as predicted]

Tested markers independent samples (n=102) via PCR Ongoing 16 markers [so far]

6 marker combinations (9 markers) gives 90.9% sensitivity and 74.7% specificity for identifying samples from patients in the Bacterial Meningitis group (Accuracy 76% [78/102] - AUC 0.81).

10 marker combinations (12 markers) gives 100% sensitivity and 71.8% specificity for identifying samples from patients in the BM group (Accuracy 75% [61/81] - AUC 0.86).

Non-Bacterial Final Diag. (n=45)

Abx No-Abx Proportion on Abx

Clinical

27 18

0.60

Gene score

14 31

0.31

Using the score could significantly reduce Antibiotic prescribing p=0.011

Biomarkers can also help rationalise treatment of brain infections

Next steps for Bacterial Meningitis Biomarkers

Further collaborative agreement between UoL and FTD. Agreement involves UoL providing knowledge on markers, marker combinations and provide sample sets to test assays. FTD provide knowledge/expertise on PCR primer selection and assay (including multiplex) development. Business Gateway has reviewed the intellectual property of the marker combination and secured permission from University of Liverpool to file a patent application. As bacterial meningitis is relatively rare in the UK we will aim to continue the UK Meningitis study to collecting further sets of blood samples on which to test the assays

Further steps in host diagnostics New tests to help detect CNS infection

- NIHR HTA – BASICS – ‘Baculoseal Against Silver Impregnated Catheter Study ‘ follow-on diagnostic study.

- WHO Searo – National Nepalese encephalitis aetiology study

Examine broader infection sets - Collect / examine samples for discriminating between viral and bacterial infection.

Any questions?

Contact: Mike Griffiths griffmj@liv.ac.uk

Thanks Gosia Wnek

Ryan Keh Fiona McGill Graeme Hickey Ajit Rayamajhi Alison Hardy Conor Mallucci Bill Carman Tom Solomon

Novel models for testing new therapeutic agents

Professor Craig Winstanley Professor of Bacteriology

Prof. Aras Kadioglu Dr Jo Fothergill

My research interests

use of genomics and molecular techniques to study the evolution, population behaviour, transmission and pathogenicity of Gram-negative pathogens, including Campylobacter, and Escherichia coli, but with a particular focus on Pseudomonas aeruginosa lung infections

Pseudomonas aeruginosa – an opportunistic pathogen

endocarditis

respiratory

infections bacteraemia

CNS

infections ear

infections

eye

infections

urinary tract

infections GI tract

infections

bone & joint

infections

wound /

burns

infections

Large genome – adaptable & metabolically versatile

Intrinsic resistance to antibiotics

Efflux pumps (eg. MexAB-OprM)

Beta-lactamases (eg. AmpC)

Low permeability (eg. OprD porin)

Hypermutators

Resistance can also be acquired

General properties of P. aeruginosa

Chronic pulmonary infection

Tissue damage &

Inflammatory exacerbations

Hospitalisation and IV

therapy

Impaired mucociliary

clearance

Cystic Fibrosis

Serosal side

Lumen

• cftr mutations

• Carrier rate = 1 in 25

• 1 in 2500 live births in UK

P. aeruginosa in the Cystic Fibrosis lung

Switch to mucoidy =

chronic debilitating

pulmonary infection

Barrier against

phagocytic cells and

effective opsonisation -

antibodies are denied

access to antigens large numbers of

neutrophils are

attracted, leading to

immune system-

mediated tissue

damage

biofilm forms a barrier to

antimicrobial agents

INFLAMMATORY

EXACERBATIONS

Hospitalisation

& IV therapy

Artificial sputum

medium (ASM) biofilm

model

CF sputum

Mucin, lipids, DNA, amino

acids

P. aeruginosa grown in ASM

Grows in a biofilm typical of CF

Phenotypic diversificiation

LESB58 in ASM

for 7 days

ASM

Resembles CF sputum

Use of Artificial Sputum Medium to Test Antibiotic Efficacy Against P. aeruginosa

Kirchner et al. J. Vis. Exp. 2012 64:e3857

Nature Comm 5:4780

Natural inhalation murine model for studying adaptation and testing new therapeutic agents

0 1 2 3 5 7 14 21 28 DAYS

LESB65

• Suggests that long term persistence in the nasopharynx allowed reseeding of the lower respiratory compartment.

• Biofilm-associated genes are expressed. • Bacteria show signs of adaptation

Naso

Naso Lung

Lung

Rechallenge Experiments

Evolved isolates clearly outperformed the original LESB65 isolate in vivo.

Model can be used for at least 28 days

“evolved” isolates “evolved” isolate

NASOPHARYNX LUNG

original isolate original isolate

Toxin sequestration therapy for treatment of severe bacterial respiratory

infection and sepsis

Aras Kadioglu

Department of Clinical Infection, Microbiology & Immunology

Streptococcus pneumoniae (pneumococcus)

Over 1 million deaths per year mainly in infants, elderly and

immunocompromised

Kills more children under 5yrs old, than measles, malaria and HIV-

AIDS combined

Most common cause of bacterial respiratory infection in the UK;

main cause of community-acquired pneumonia (~70%)

Novel treatments against invasive pneumococcal disease

[1] Target the immune system –

P4 peptide immunotherapy - MRC DPFS funded

[2] Target major bacterial virulence factor –

Liposome Toxin sequestration therapy

Pneumolysin

• Protein toxin produced by

all clinical isolates.

• Lytic toxin, able to bind to

and lyse all cells that have

cholesterol in their

membranes.

• Highly pro-inflammatory at

sub-lytic concentrations

• High levels correlate with

poor patient outcome

Bacterial Pore-Forming Toxins

Cholesterol Dependent Cytolysins (CDC) - Toxins from 24 different Gram-positive

bacterial species – food poisoning, gas gangrene, necrosis, meningitis, pneumonia

Clostridium perfringens Perfringolysin

Streptococcus pneumoniae Pneumolysin

Streptococcus pyogenes Streptolysin

Streptococcus suis Suilysin

Listeria monocytogenes Listeriolysin

Bacillus cereus Cereolysin

Staphylococcus aureus Alpha hemolysin

Liposomes

• Artificial lipid vesicles composed of naturally occurring

lipids.

• Can be loaded with artificially high cholesterol concentrations.

Our question: Could bacterial toxins bind to cholesterol enriched liposomes instead

of host cells?

Could liposomes act as decoys during infection?

Liposomes are effective against a wide range of bacterial toxins

Streptolysin O Tetanolysin Pneumolysin Phospholipase C α-hemolysin

S. pyogenes C. tetani S. pneumoniae C. perfringens S. aureus

Lysis of human epithelial and endothelial cells by pneumolysin is prevented by

liposome treatment

Epithelial cells - transfected with a cytoplasmic

yellow-fluorescent protein, lose their cytoplasm

after permeabilization by PLY (200 ng) in the

absence of liposomes.

In contrast, when Ch:Sm liposomes (100 μg) were added, the

loss of the cytoplasm (cell lysis) was prevented

liposomes prevented lysis of HUVEC endothelial cells by PLY

(200 ng)

Liposome treatment against pneumococcal pneumonia

Control : 40% survival

+ Liposomes: 80% survival

Control : 0% survival

+ 6h liposome treatment : 70% survival

+ 10h liposome treatment: 50% survival

+ 16h liposome treatment: No difference

Liposome treatment against pneumococcal sepsis

Adjunct therapy with liposomes against bacterial sepsis

Control : 0% survival

Antibiotic alone: 40% survival

Antibiotic + liposome treatment at 10hrs : 80% survival

Advantages of Liposome Therapy

• Non-toxic and already used for drug and vaccine delivery

• Inexpensive, stable and easy to administer

• Broad spectrum liposomes effective against all bacterial toxins tested

• Targeting bacterial toxins unlikely to lead to drug resistance

• Protects major targets of bacterial toxins. i.e. host immune cells, epithelial &

endothelial cells

• Reduces toxin driven inflammation – a key factor in bacterial sepsis

Laura Bricio-Moreno

Suzy Gore

Dan Neill

Hesham Malak

Ecological assessment of the direct and indirect effects of routine rotavirus vaccination in Merseyside, UK

Nigel A Cunliffe Professor of Medical Microbiology

Institute of Infection and Global Health

Estimated incidence of infectious intestinal disease in children <5 years in England

• Hospital episodes1 ~ 41,000 episodes per year (Primary diag - ICD10 A00-A09)

• GP consultations2 – ~85 per 1,000 person-years - highest rate of any age group

– Equivalent to ~270,000 GP consultations per year

• NHS direct/NHS24 consultations in England2 – ~113 per 1,000 person-years <1 year olds –highest rate

– ~32 per 1,000 person-years 1-4 year olds

– Equivalent to ~150, 000 community consultations per year

• Community cases in the England2 – ~1079 per 1,000 person-years <1 year olds –highest rate

– ~713 per 1,000 person-years 1-4 year olds

– Equivalent to upto 10 million cases in England

1. HSCIC. Hospital episode statistics. Admitted patient care, England–2012–13: diagnosis. Health and Social Care Information Centre, 2014. 2. 2. Tam C, et al. Gut 2012;61:69-77 / https://www.food.gov.uk/science/research/foodborneillness/b14programme/b14projlist/b18021

Global surveillance shows that 40% of diarrhoeal hospitalizations are due to rotavirus

Rotavirus is the most common cause of severe, dehydrating diarrhoea among children < 5 yrs worldwide

Each year it causes:

•111 million diarrhoea cases

•25 million outpatient visits

•2 million hospitalizations

•450,000 deaths

Current rotavirus vaccines

Rotarix®

GlaxoSmithKline

RotaTeq®

Merck & Co

Indication

For the active immunisation of infants aged ≥6 weeks against RVGE

Composition

Live attenuated monovalent human rotavirus

strain

G1P[8]

Live attenuated pentavalent bovine (WC3)-

human reassortant strains

G1P[5]; G2P[5]; G3P[5]; G4P[5]; G6P[8]

Form Orally administered in liquid formulation

Administration

Two doses

First dose from 6 weeks of age

Minimum of 4 weeks between doses

Schedule should be completed by 24

weeks of age

Three doses

First dose between 6 and 12 weeks of age

Minimum of 4 weeks between doses

Schedule should be completed by 26

weeks of age

Information based on summary of product characteristics RVGE = rotavirus gastroenteritis

USA: Laboratory Reports

Lopman et al;Curr Opin Virol. 2012 Aug;2(4):434-42

Rotavirus vaccine has been introduced in the UK!

Aims

• To use routine health data sources to estimate the direct and indirect effects (herd) of vaccination on a range of outcome indicators and the relationship of such effects to vaccine coverage and socio-demographic indicators.

• Identify key areas that require improved data collection tools to maximise the usefulness of this surveillance approach.

• To produce a learning resource and template for ecological vaccine effectiveness studies in the UK

Study design

Design Ecological study – before and after approach

Location Merseyside ~1.4 million pop ~ 80,000<5 years

Population All ages, not just vaccine eligible age

Data Routine health surveillance and clinical data

Case definition

Differs for each dataset / outcome measures – clinical, laboratory confirmation and syndromic

Study period >= 3 years pre-vaccine and 1-3 years post

Data set Case definition

Nosocomial and community acquired

Nosocomial—laboratory-confirmed rotavirus case. Gastroenteritis symptoms beginning >2 days after admission Community acquired—laboratory-confirmed rotavirus case. Gastroenteritis symptoms <3 days of admission

Hospital admissions Rotavirus case—inpatient FCE with a primary or subsidiary diagnosis ICD10 A08.0 AGE case—inpatient FCE with a primary or subsidiary diagnosis ICD10 A08–A09

ED attendances Attendance with a primary or secondary diagnosis code Z:III Gastrointestinal conditions––other

GP consultations

GP consultations (Read codes): diarrhoea and vomiting (19G); diarrhoea symptom NOS (19F6), viral gastroenteritis (A07y0), diarrhoea (19F2); gastroenteritis—presumed infectious origin (A0812), diarrhoea of presumed infectious origin (A083); infantile viral gastroenteritis (A07y1); infectious gastroenteritis (A0803); enteritis due to rotavirus (A0762); and infectious diarrhoea (A082).

Community consultations (Walk-in Centres)

Variable coding system for diagnosis. Patient consultation field will be queried using the following key words: diarrhoea, vomiting, GI and gastroenteritis. A Soundex script will be used to allow for spelling inaccuracies

Laboratory detections Detection of rotavirus in a faecal specimen by a standard assay Detection of other AGE causative organisms

Case definitions by health data set

Outcomes

• Change in trends of gastroenteritis indicators and rotavirus diarrhoea rates during the first three years post vaccine introduction.

• Relative impact on various services (i.e. GP consultations, A&E attendances, hospital admission, walk-in centres and telephone consultation).

• Measure of direct (those vaccinated) and indirect (not vaccinated) impact on overall gastroenteritis.

• Assessment of the effect of deprivation on vaccination uptake and incidence of gastroenteritis.

Alder Hey Rotavirus Lab Data

• (+) laboratory detections 07-2004 to 04/2014

Acknowledgements

Dan Hungerford, Miren Iturriza-Gomara, Jon Read, Neil French

Roberto Vivancos

HIV / Hepatitis Drug Interactions

Saye Khoo

Institute of Translational Medicine

The Problem ….. • Global burden of HIV (37M), HCV (170M) and hepatitis B.

• Notwithstanding success, HIV & HCV therapy carry liability for harm from drug-drug interactions (DDI)

• Global surveys (US, EU, SSA) suggest 1 in 4 treated patients have clinically significant DDIs, yet clinicians able to identify only a third

• Patient population is ageing, with multiple co-morbidities, and liver/renal dysfunction – multiple medications from multiple sources

• 5.2% of HIV hospital admissions receiving contraindicated medicines

• Available resources provide inadequate coverage

Gallagher et al CID 2008;47:e36

Our Solution ….. • Online and smartphone/tablet prescribing support.

• a clinically useful, reliable, comprehensive, up-to-date, evidence-based resource, freely available to healthcare workers, patients and researchers

• Covers all known data, predicts unknown, advises management

• Data synthesis - HIV (>11,000 DDI-pairs) and HCV (>5,000 DDI-pairs) from wide range of sources – updated weekly

• ‘Traffic lights’ recommendations, paired with GRADE-based evidence evaluation

• Supported by Pharma, British HIV Association, European AIDS Clinical Society, Elton John AIDS Foundation, Glasgow HIV Conference, NIHR

• Governance (International Editorial Board) and patient involvement

• Covers WHO Essential Medicines List

A Brief History

1998 1st HIV Charts launched

1999 We went ‘Digital’

2002 Partnership with KP360

2006 Website redeveloped to current form

2009 Editorial Board – ‘internationalised’ stakeholders

2013 Electronic prescribing in Kampala

2011 Hepatitis website launched 1st App launched – iOS and Android

HIV iCharts

Hep iCharts

What should ‘success’ look like ? • Acknowledged to be the ‘Premier’ DDI resource - resource for Treatment Guidelines in > 16 countries/territories - UK Standards & BHIVA Guidelines require every GP letter to carry URL - partnered with major specialist societies in Europe and USA

• Web metrics (Google analytics) - Unique users/y – 105,000 (HIV) and 35,500 (Hep)- rising year-on-year - multiple territories - App downloads: >55,000 (HIV); >13,000 (Hep)

• External funding - Pharma funding (£1.3M in past 5 years) - Buy in from Specialist societies and charities

What could we have done better ? • Fundraise, especially from charities • Define ownership and controls right from inception code, content management, URL, publisher • Horizon scan NHS Apps, MHRA and EDD

What would we do with a million dollars ? • Modernise website – declutter, mobile-optimised, user experience • Equip for 21st century prescribing – electronic prescribing • Patient-friendly/ 3rd party Apps / translations • Personalise – exploit in-silico tools • Expand – other infections, cancer • Restructure for research

HIV Drug Monitoring

• Patient responses and drug exposures variable • Adherence is a major problem • Vulnerable groups and risky situations

• Drug monitoring for individualised therapy • Incorporated into Guidelines 2003 • Spun out in 2006 (now incorporated into Lab21)

• GCP lab (4 triple quad LC/MS systems) • HIV/HCV/TB drugs • Plasma, tissues, fluids, cells • Dried blood/plasma/breast milk spots

http://www.liv.ac.uk/translational-medicine/research/bioanalytical-facility/about/

LC- MS/MS

Chromatography

Q & As

Lunch, networking and booked 1:1s

HASHTAG FOR THE EVENT #InfectionCatalyst

Company elevator pitches

HASHTAG FOR THE EVENT #InfectionCatalyst

IMPLEMENTING BEST

PRACTICE IN THE

NHS

Martin Kiernan, Visiting Clinical Fellow, UWL

Rise of S. aureus bacteraemia England 1991-2003

181

Slide adapted from Susan Hopkins, HPA/PHE

MRSA

MSSA

C. diff Annual Cases (England) Data source: Health Protection Agency

182

0

10000

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182

Getting engagement 183

Staff have to believe that they can make a difference

and can prevent infection

Tricky

We do not implement the organisations IPC programme

How C. difficile get so bad?

OK, there were some changes

Healthcare practice

Patient risk profile, Age

Increase in Community CdI

Effect of new strains (027/NAP1) that demonstrated that

Infection Control was not working

The authors of a 2009 report stated

‘it is the failure to implement the guidelines described in 1994

that has contributed to the recent rise’

184

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Quarterly C. difficile England >2y: 2004-2014

0

2000

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10000

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18000 Surveillance

Problems in detection of CDI?

Testing and sampling protocols vary significantly

Lab interpretation of what you see in front of them does

not always reflect what the nurse sees in front of them..

186

People are plotting against us

What about a type 7 stool on a incontinence pad?

Scrape up a lump? – tested? – not ‘shape of the container’

No ¼ of a container

187

Specimen testing 188

Do we get specimens from every diarrhoeal

patient?

Experience says not

E-reader to all staff to ask them to write the Bristol

Stool Chart score 5-7 on the form

Compliance <100%, but it had an impact

Impact of Specimen e-reader M

ay-1

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Specim

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Period

Monthly Faecal Specimens from inpatients 2013-15

Isolation - Let’s play Trumps.. 190

You have competing priorities, so who gets the side room?

Isola

tion

MDR GNB

Carbapenem-resistant Enterobacteriaceae

Carbapenem-resistant A. baumannii

ESBL Klebsiella sp

Carbapenemase-producing P. aeruginosa

ESBL E coli and other Enterobacteriaceae

AmpC Enterobacteriaceae

CDI

MRSA

Norovirus

Influenza

TB

Etc, etc.. 191

192

Quarterly MRSA Bacteraemia England: 2001-14

0

500

1000

1500

2000

2500

Surveillance

What does this mean

England has gone from 434 HAI cases/month (Jan 2006) to 15 in November 2014; a 96.7% reduction

Annual totals still falling by 8.4% per month

How did the NHS do this?

Good practice (and a big stick)

In my organisation, no cases for 2.5 years – until recently

1 missed screen in a haematology patient – parotitis treated with the wrong antibiotics

1 osteomyelitis – treatment failure that was missed

193

You have a problem and you are going to

fix it

We have a problem, how will you fix it?

We have a problem, how do we fix it?

Do we have a problem? How should

we fix it?

Solution

194

Southport ITU

2010 - IC Team feel that Central Catheter-related

Bloodstream Infections are too high

Clinicians do not…

But have no idea what their rate is

Data collected

Rate of infection 10.97/1000 device days

Ah…. I asked them to write why this was down on a

post-it note

195

Receiving Bad News: Five stages of grief

Kübler-Ross

Denial

Anger

Bargaining

Depression

Acceptance

CR and CA-BSI in ITU 2009-14 Rate/1000 device days

10.97

3.58

1.48 2.22

1.35 1.17

0

2

4

6

8

10

12

2009 2010 2011 2012 2013 2014

Antibiotic prescribing

Standard for stop/review dates and indications was

80%

Wards were audited

Multiple clinical teams per ward with outlying patients

No ownership from clinicians

Ward Managers felt the pressure

We never hit the standard

198

Audit of prescribing Stop/review dates by hospital ward

199

Target 80%

Actual 77%

Antibiotic prescribing

We did two things

We increased the standard from 80% to 90%

Possibly a lower standard did not demonstrate a true desire

for high quality prescribing

We changed method to audit by clinician teams not

wards

200

Antibiotic Prescribing Getting Personal - Stop/Review Dates 2012-14

201

IPC Programme

We need to find a way of better ways of engaging with

those who will deliver the programme

I had the worst job title in the world; I controlled nothing

What motivates people?

What are their desires….. or fears..

202

Motivators

204

Advance pre pre-op 2% CHG reduces incidence of SSI in knee

arthroplasty Zyweil et al. International Orthopedics 2010 Epub

SSI in Breast Surgery 205

All infected with Staph. aureus

Commonly found in the axilla

Consideration to pre-op washing

It works, however non-compliance an issue

Zyweil et al. International Orthopedics (2010)

Pre-op skin disinfection

Wide variation in skin prep

2% CHG in Alcohol introduced as the only change

Infection rate is 1.0% over the past 12 months

So let’s see if a bundle works 206

Implemented a 9-point bundle

Antiseptic bathing

2% Alcoholic Chlorhexidine

MRSA Screening

Abx prophylaxis

Normothermia

Iodine incise drapes

Supplemental Oxygen

Glucose control

No hair removal or clippers

SSIs pre and post

Baseline (127) Cohort (166)

Superficial SSIs 9% 17%

Deep SSIs 15% 11%

Total SSIs 24% 28%

Compliance with interventions

Baseline Cohort MRSA screening, decontamination

88% 89%

Pre-op wash 63% 63%

App. hair removal Not recorded 100%

App. antibiotic prophylaxis 75% 73%

Skin prep 2% CHG Not used 63%

Normothermia 23% 35%

Iodine incise drapes Not recorded 100%

Supplemental oxygen Not recorded 100%

Glucose for diabetics 98% 95%

What scares me?

MDROs

209

2012

2004-9

Getting research into practice is the

greatest challenge

There are variety of reasons, but one of the primary is

the failure of those developing an intervention to truly

consider how (and if) it could be implemented

We need good qualitative studies to determine the

reasons for non-implementation

210

Coffee / tea and networking

NWC AHSN and the Patient Safety Collaborative

Prof John Goodacre, NWC AHSN

Follow us on Twitter @NWCAHSN @LiverpoolUni

Wrap up, next steps and close

Drinks reception, networking and 1:1s